Healthcare Provider Details

I. General information

NPI: 1689976730
Provider Name (Legal Business Name): PHYSICIANS HEALTH ALLIANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 QUINCY AVE 1A
SCRANTON PA
18510-1739
US

IV. Provider business mailing address

1401 ELECTRIC ST
DUNMORE PA
18509-2098
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-5253
  • Fax: 570-342-6038
Mailing address:
  • Phone: 570-969-9005
  • Fax: 570-207-0706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2563602
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD
# 2
Identifier1007712910043
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: PATRICIA KANE
Title or Position: COO
Credential:
Phone: 570-969-9005